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APPLICATION FOR WELLIPUMP PERMIT <br /> �414AN JOAQUIN COUNTY PUBLIC HEALTH SERVICY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388 304 EAST WEBER AVEMUE,3TOCKTON, CA 9=1-M <br /> (209) UR-3420 <br /> OWREMI ABLE PERMIT EXPIPES i YEAH FROM GATE ISSUED <br /> icB"b%II Tri'wto <br /> APKXATNIN fS HE E SY MADE TO THE SAN JOAOUSI COUNTY FOR A PERMIT TO CONSTRICT ANDAM WSrALL THE WORK DESCRBSED.TIWS APPLICATION IB MAGE IN coLv IA►ICE VMW SAN <br /> JOAOLNN COUNTY OEVELOPMEEN]T TITLE,CHAPTER 9-111!:.3 APM TRf STANDARDS OF SAN JOAOUIH COUNFY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMam, <br /> JOB ADDESSIOR APW V ��� Zmez CTI PARCEL MMAPNO <br /> OWNER*NAME11 �j• '=.�j� _. _ADDRESS <br /> .�rRyH°"E" .5Z3/Z� <br /> coNrRAcroR ADDRESD /O It <br /> ♦�►po�c /r,P1101VE r 0+ 7 <br /> aUB CGNTRACTGII ADDRESS L1Cr w <br /> PHONE s <br /> Type MeZMARNM El <br /> Raw WELL 13 REPLACeww weLL Mowromm WELL r 1 3 cum <br /> 13 owTALLAum 13 WELL smem REPAIR D CROSS-CONNECT REPAIR 1.3 VAPOR ExTNRACTION WELL r <br /> fIYPE OF <br /> D Hwa 13 nw* H.P. DEPTH PUMP SET NT. FIRST WATER LEVEL O <br /> NIrAP) <br /> 13 <br /> OUT-OF-SERVICE WELL ❑GEGPIHYBICAL WELL J Boom B <br /> 13> ,CT1DeR <br /> 13 WOUSMAL 13 OPEN BOTTOM DIA,OF WELL EXCAVATION G _ DIA.OF CONDUCTOR CASINO N1l* p <br /> 13 DOMESHC/AIVATE 0 GRAVEL PACKRWE TYPE OF CASM/STERA VC •':• DIA.OF WELL CASINO p <br /> PLELICmmxoCIPAL ❑wvVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 13 NBFGATIOWAG 1GTHER GROUT SEAL WMALL.ED BY• M^1 DIAL , L WIM BRANIO NAME L Lr <br /> .01 <br /> uprwwOSB �y� f BMW SEAL PUMPEO: 0 Y« IJ N. CONCRETE PEDESTAL BV 111S11R;:13 v� a <br /> APP003L BATH 2D Lomwm CHESTER SOxmOVE WPE S <br /> PIIOPOM CONSTIIIICMNIDPKAM METHOD MUD ROTARY ABI ROTARY AUGER CABLE <br /> 1 HERBY CERTIFY THAT I HAVE PREPARE TIID APPLICATION AND THAT THE WORK WILL BE HONE N ACCOROANCE WrTH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,ARID RULES AND <br /> MMKATIDNB OF TNF GAL)JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATURE CLU1'rWEi THE FOLLOWsq:'1 CERTIFY THAT IN THE PERF'O1MrANCE OF THE WON(FOR WHICH <br /> THIS Pa" N IMLRO,I SHALL NOT EMPLOY r'EASONS SUBJECT TO WORT MAN'S COWIN AT10N LAWS OF CAtV4WSA.' CONTRACTOR:MWM OR WS-CONTMCTIIO MONATIBE Cr9 TP" <br /> TRE FOUR ANG, 'I CERTIFY THAT IN THE PER POTO /ICE OF THE WORK PMI WHICH TMD PERM to ISSUED.1 SHALL 04"W PERSONS SUBJECT To 1MONIONAN'S CGSSPLDIDATRW LAWS OF <br /> CALPOIMSA.' TIE A"WANT MUST NI ADVANCE POR ALL REOIIIRBD W"W'IONS AT IMP I4@4bl"- COMPLETE DRAWING AT LOWER AREA PHOVOW. ^QJ <br /> 3{r'fJ6J^i'8/,GLy/J Tom bay m <br /> ROT PLAN Wrow ro So"Bar •is <br /> 1. NAMES Of STARE"OR ROAD@ NEAREST TO OR BOUNCING THE PROPEIITY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYrTEM OR PROPOBEb <br /> !.OUTLUE OF THE PROPERTY.OIVNIG DIMENSIONS AND NORTH DNECTION. EXPANBION OF SEWAGE DIDPOSAL SYSTEMS. <br /> a. DIMMSIONEf OUTLINED AND LOCATION OF ALL fX"" NO AND PROPOSED S. LOCATION OF WELLS WFFHI N RADIUS OF ONE HUNMED FF'TY FT. <br /> STFUCTiN K INCLUDING COVERED AREAS OUCH AB PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOIABNG PROPERTY. <br /> c. <br /> T•' <br /> -.._ :.... .:. r <br /> a . <br /> „._... -.. .. •tom. <br /> .... h.. ..E....,.t..._....,.... -- <br /> : <br /> D..BPARTMBT USE ONLY <br /> APPB. l.nAwP.dp `������� <br /> DH. iY7 Arr C.• •�� 7�AI <br /> Owu�+r.nllw+Ily D.R. PWW dwP.edon Sr O.h <br /> owt,wlMn M+P.."I Dr Dn. <br /> Cam m <br /> Acoo1HNTN/B I NLYK AUDI FACT <br /> PE LIODED M INFO AMOUNT N001 I ID EIKCUICASH RBCBVfb IY DA PI T/S9RIACE RIOUWT NUMBER INVOICE <br /> Pub,HedM Swv.-Enviro.173 rOM <br />